08727-62 Universal Claim

From:_____ Fax to: Claims No#of pages:_____ Phone Number: Or Mail to: Box 100195 Universal Claim Form Columbia SC 29202-3266. Please be sure to send the following Information: Medical Documentation for your condition Diagnosis (ICD9) codes, Signed and dated authorization Fax this direction. OPTIONAL SERVICE RELEASE AGREEMENT Please initial below for optional services. Any other marks used (check mark, x, etc.) will not be considered as authorization and will be processed as blank. I authorize Colonial Life to facilitate processing this Claim by releasing its details to the individual inquiring on my behalf. Leave blank if you do not want anyone accessing your Claim information. _____sales representative _____ plan administrator _____spouse, family member or significant other _____I want Colonial Life to update me on the status of my Claim through electronic messaging at my home phone number indicated on this form.

Colonial Life & Accident Insurance Company UNIVERSAL CLAIM FORM Fax: 1-800-880-9325 elephone: 1-800-325-438 Claim Fraud Statements Before signing this claim form, please read the warning for the state where you reside and for the state where the insurance policy under which you are claiming a benefit is issued.

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